CHOCTAW ASSET BUILDING IDA PARTICIPANT APPLICATION

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Katrina Rodgers
7 years ago
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CHOCTAW ASSET BUILDING IDA PARTICIPANT APPLICATION P.O. Box 1210, Durant, OK 74701 (580) 920-2260/(580) 920-0453 FAX APPLICANT/PARTICIPANT DETAILS HEAD OF HOUSEHOLD Y / N Last Name: First Name:

1 CHOCTAW ASSET BUILDING IDA PARTICIPANT APPLICATION P.O. Box 1210, Durant, OK (580) /(580) FAX APPLICANT/PARTICIPANT DETAILS HEAD OF HOUSEHOLD Y / N Last Name: First Name: Initial: Last four digits of Social Security Number: Tribe: Phone: Cell: Street Address: Mailing Address: City and State: Zip Code: County: Emergency Contact Name: Phone: Relation: Street Address: Mailing: City/State : ZIP Code: Emergency Contact Name: Phone: Relation: Street Address: Mailing: City/State: ZIP Code: TANF Currently Eligible Currently Receiving Has Ever Received Yes No Yes No Yes No Federal EITC Yes No Yes No Yes No State EITC Yes No Yes No Yes No Number of Adults in Household* Number of Children in Household Total number in Household If the number of household members is different on your application vs. your tax form, please attach an explanation. Annual Income: $ Documentation Method: 20 Income Tax Three Current Check Stubs 1099 wages (self-employed) Other: Date of the documentation (i.e., date tax form completed, date of last pay stub, etc.) Note: Please see attached Page 2 for Required forms of Documentation. Other income(the following income types are collected for data purposes, but are not used for determining eligibility) Alimony Payment: Child Support: SSI/SSD: Food Stamps: $ $ $ $ Provide most recent credit score: Credit Bureau Source: Date: Note: Your IDA Coach will pull a credit score if you do not have one available. 1

2 Attached to this application are the following required documents:! Verification of Household Income and Earned Income Most recent IRS tax form and One current paystub, OR Self-employment tax 1099 OR Personal declaration of income into the household, with contact information If not obligated to file tax returns: Three (3) current employment pay stubs for household members, OR Self-employment tax forms (1099), OR Personal declaration of income into the household, with contact information.! Household Net Worth Verifications (proof of debt using attached sheet)! Verification of Residency (circle one document from the following list of options) utility bill; tribal registration card; voter registration card; rental/lease agreement; social services statement! Verification of Age (circle one document from the following list of options) State ID; Birth Certificate; Passport; Tribal Registration card! Verification of Citizenship (circle one document from the following list of options) Tribal registration card; US Passport; birth certificate; Social Security Card CAB Application 2

3 Assets Yes No Value Balance Due Principal residence Own other homes Business Ownership Other Property or real estate Investments(401K,IRA,Stocks,other) Checking Account Saving Account Vehicle 1 Vehicle 2 Vehicle 3 Year & Make Model Mileage Value Balance due Liabilities Yes No Outstanding bills past due Student loan outstanding balances Medical bills outstanding balances Personal loan outstanding balances Credit card outstanding balances Payday Loans All other liabilities AFI Net Worth (excludes primary residence and primary vehicle) Total Assets $ Total Debts -$ = Net Worth (includes all assets) $ CAB Application 3

4 I have provided proof of my debt in order to determine the net worth of my household: Applicant Signature CAB Application 4

5 CHOCTAW ASSET BUILDING APPLICANT/PARTICIPANT BACKGROUND INFORMATION Gender: Male Female Tribe: Degree Blood Quantum Marital Status: Single (Never Married) Married Separated Divorced Widowed Other Unknown Date of Birth: Mother s Maiden Name: Employment Status: Full Time Employed Part Time Employed Retired Unemployed Student Other Unknown Place of Employment: Street Address: Mailing Address (if different) Telephone: Fax: City: State: ZIP Code: Highest Level of Education Completed: Completed grades K-5 Completed grades 6-8 Completed grades 9-11 High School Diploma/GED Vocational School Diploma/Degree Some College AA Degree/Graduated Two Year College BA/BS Degree/Graduated Four Year College Some Graduate School/Attended Graduate School MA/MS Graduate Degree(s) Unknown Residential location at time of Enrollment: Major Urban Area (metropolitan statistical area with population greater than 1,000,000 Minor Urban Area (metropolitan statistical area with population between 50,000 and 1,000,000 Rural Area (less than 50,000) Remote Area (less than 2,500) Unknown Anticipated Asset Type: First Home Purchase (haven t owned a home in the past three years) Higher Education Business Capitalization: Unknown: Have you ever used Direct Deposit procedure for your paycheck prior to IDA participation? Yes No Have you ever used Fringed (pre- taxed) Financial Services? Yes No Do you or have you ever used a spending plan or a budget? Yes No CAB Application 5

6 By signing below, I verify that the information that I have provided is true to the best of my knowledge. I have fully disclosed the financial situation of my household, as well as provided full information on all my financial institution accounts. If I have intentionally provided any incorrect information or am found to be out of compliance with the standards of this initiative I may be asked to withdraw my participation. I agree to allow the organization to pull my credit at the time I am authorized to open an IDA Account, as well as when I am ready to purchase an asset in order to establish a beginning and ending score. This is a hard pull and will be reflected on my credit record. Personal Data and Consent for Communication. I understand that all information I have provided will be treated as confidential. I consent to allow this information to be shared with the IDA administrating agency (The Choctaw Nation of Oklahoma) as necessary for data collection and reporting, as well as determining eligibility. I understand that the information provided may need to be discussed with me in the case of questions around eligibility. Participant Printed Name Witness (if translator is used) Participant Signature Date CAB Application 6

FAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) FAIM New Participant Application Form AGENCY USE ONLY : Agency Name:

FAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) AGENCY USE ONLY : FAIM New Participant Application Form Revised 05/23/14 Agency Name: Bank Account Number of 1 st Deposit Asset Grant First Name MI Last